Healthcare Provider Details

I. General information

NPI: 1801883764
Provider Name (Legal Business Name): COVENANT CARE OHIO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MARKER RD
VERSAILLES OH
45380-9494
US

IV. Provider business mailing address

200 MARKER RD
VERSAILLES OH
45380-9494
US

V. Phone/Fax

Practice location:
  • Phone: 937-526-5570
  • Fax: 937-526-9630
Mailing address:
  • Phone: 937-526-5570
  • Fax: 937-526-9630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5461
License Number StateOH

VIII. Authorized Official

Name: CAROL A SPARKS
Title or Position: DIRECTOR OF REIMBURSEMENT
Credential:
Phone: 949-349-1200